Provider Demographics
NPI:1073606661
Name:PEDERSEN, JENNIFER R (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1705
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30903-1705
Mailing Address - Country:US
Mailing Address - Phone:706-774-7760
Mailing Address - Fax:706-774-7766
Practice Address - Street 1:4321 UNIVERSITY PKWY STE 101
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809
Practice Address - Country:US
Practice Address - Phone:706-774-5995
Practice Address - Fax:706-774-5996
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052616207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000957932BMedicaid
SCG52616Medicaid
SCG52616Medicaid
GA46BBBHMMedicare ID - Type UnspecifiedGA MEDICARE